Migraines and Big Life Changes

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Starting a new career? Moving across the country? Going through menopause? It’s hard to know how your migraines will respond to life shifts.

Get familiar with your options and learn about strategies to help minimize the impact of potentially stressful situations. Join in as our guests answer your questions about transitions, including the effects of changing hormone levels, how to minimize your triggers and when it’s time for a new treatment plan.

As always, our expert guests take questions from the audience.

Announcer:
Welcome to this HealthTalk show. Before we begin, we remind you that the opinions expressed on this show are solely the views of our guests. They are not necessarily the views of HealthTalk or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Now, here's your host, Rick Turner.

Rick Turner:
And hello and welcome to our show, Migraines and Big Life Changes. I'm Rick Turner. The cycle of life is filled with change from the onset of puberty to marriage, children, to retirement. We all know that change is never easy, but does it affect your migraines, and if so, how? Well, in this show, our expert guest will discuss how life's big changes can exacerbate or sometimes mollify migraines. We will discuss hormonal and physiological changes based on gender and age and then talk you through some of life's big, and not so big, stressors and identify potential triggers, so you can begin to control symptoms and get the right treatment for the right time of life.

Joining us today is Dr. Sheena Aurora, M.D, director of the Swedish Headache Center and the Swedish Pain and Headache Center in Seattle, Washington. She is a member of the American Academy of Neurology, the American Association for the Study of Headache, the American Association of Electrodiagnostic Medicine and the International Headache Society. Dr. Aurora has published more than 30 peer reviewed manuscripts, and she presents lectures about migraine headaches and pain at several forums around the world, and she joins us today.

Welcome, Dr. Aurora.

Dr. Sheena Aurora:
Thank you very much, Rick. It is my pleasure to be here.

Rick:
We appreciate your time today. I guess you could say that migraines can become a part of our lives even before we are born, in the sense that 70 to 80 percent of migraineurs have a family history of the headaches. Doctor, can you tell us about that family connection? Is it genetics? What does the research tell us?

Dr. Aurora:
Most of our research has shown that 80 percent of people who have migraines have at least one first degree relative who has migraines, so it does seem to have a really strong genetic predisposition. We've also been able to link some of the genes for rare forms of migraines. At this time, 33 million Americans, according to surveys, suffer from migraines, so we will never be able to have one gene that would be linked to migraines.

But some of the very, very rare forms of migraine have been linked to three genes that we know of. And what we can glean from that research is that those genes make the brain more susceptible in terms of going into a migraine. So people with migraines genetically are predisposed to have a more hyperexcitable or a hypersensitive brain.

Rick:
We see that predisposition used in describing so many chronic illnesses. It doesn't mean that you're definitely going to get it, but you just have a higher likelihood.

Dr. Aurora:
That's right.

Rick:
And you also used the term "first degree relative." What does that mean?

Dr. Aurora:
That means mother, father, brother or sister, or the grandfather or grandmother.

Rick:
Do babies or children get migraines? And if so, what symptoms do they present?

Dr. Aurora:
It's not very clear, but we do think that babies sometimes will get pale periodically. They can have maybe some fits of vomiting, which we call cyclical vomiting, and that later on matures into migraine disorders. People who, when they are younger have motion sickness, sometimes as they grow older will have migraines.

Rick:
So in terms of diagnosing kids, obviously, before they are able to express how they are feeling, you just have to sort of glean from other indications, right?

Dr. Aurora:
Yes. The main indication to me is if somebody comes to me with a child who has cyclical vomiting or gets incoordination. Of course, we'd ruled out other things because we want to make sure, since children can't express themselves, that you are not missing another serious disorder.

But if somebody has migraines in the family, and then they have these episodes of incoordination or vomiting, then you are more likely to think that it is migraine-related.

Rick:
And in a situation where someone that young is brought to your attention, how are they treated?

Dr. Aurora:
It just depends on how frequent those episodes are. Most the time, it's quite mild and minor, and we pick it up by history when we see these individuals later. In kids, unless they have cyclical vomiting which gets them dehydrated, it's not very serious, so it doesn't need a lot of treatment.

Rick:
And when we get to slightly older children, the statistics vary, but it seems that between 7 and 18 percent of all children experience migraines, which seems like a lot. Can you describe how a child would experience migraines? Are the symptoms similar to what we see in adults?

Dr. Aurora:
The headaches themselves are shorter, and they have more nausea associated with them. They have more paleness and an incoordination sometimes associated with them, more than adults. And if children are able to go to sleep, the migraines usually get better.

Rick:
And do we have a sense of the aura that we so often see in adults?

Dr. Aurora:
If you look at the epidemiology, it's not very common. One in five people who have migraines have aura. In children, it’s about the same, so 20 percent of kids with migraines can have aura, 80 percent of the time it's visual, and they have a little light flickering. I saw a young girl with a very interesting Alice in Wonderland syndrome where things get really small, and things get really big.
Adolescence is when migraines become a problem. Most of the time, they usually don't last that long. But I have seen 12 year olds who have very frequent migraines, who are missing school, who are getting behind. So it just depends.

Rick:
And what about the differences between boys and girls, do we see much of a distinction there?

Dr. Aurora:
According to our epidemiological studies, little boys usually get more migraines than little girls statistically. And then something changes right about puberty when little girls start having more migraines. As women get into the late teens, early 20s, we definitely see much more of a gender difference, almost three to one for every female to male. And I have seen little boys grow out of migraines more than little girls do.

Rick:
One would think that since the changes start to happen around the time of puberty that hormones are playing a factor.

Dr. Aurora:
Absolutely. It's the fluctuation of hormones, yes.

Rick:
Kids might not be able to express themselves sometimes, so the onus is on parents and caregivers to observe those signs. Explain more specifically for our listeners what to look for if they suspect there might be a migraine.

Dr. Aurora:
If there a family history of headaches, watch out. Watch out for like hot days, not drinking enough during, soccer games, football. If they don't drink enough water, they get dehydrated, and, boom, a headache comes on. So look for headaches that are provoked. Once you watch out for that and you have a family history of migraines, those are probably migraines.

Rick:
And what about signs or emotional displays by a child that might be indicative that a migraine is involved?

Dr. Aurora:
Well, that is hard. I have a 3 year old at home, and at the moment he has tantrums for no reason. We've never been able to show distinctly that once people have migraines, that they become more upset. But I have noticed a behavior where the child will become more withdrawn. They will become pale. They just want to be left alone. They will feel sick. So they usually get withdrawn or pale rather than having emotional outbursts.

Rick:
In terms of common or effective treatments for kids who have migraines, what's out there?

Dr. Aurora:
Unfortunately, we don't have any prescription drugs that are approved for kids under the age of 18.
I find that what works better are the nonsteroidal anti-inflammatories like low doses of Naprosyn (naproxen) or ibuprofen that works better. But some kids respond equally well to acetaminophen (Tylenol). I think if they have a lot of vomiting or nausea, you might want to talk to your doctor about giving an anti-nausea medication. Helping the kid go to sleep and maybe giving a little bit of Benadryl (diphenhydramine) or something helps as well.

Rick:
Did you want to add anything about the fact that at the time of puberty girls have migraines more often? Is estrogen a factor there?

Dr. Aurora:
Well, we know that it's the fluctuation of the hormones, so as puberty hits and there is a lot of fluctuation of estrogen. We think that it's estrogen fluctuation rather than the progesterone fluctuation that causes or triggers migraines. But what is most fascinating to me is that people say, “Migraine is a disorder of women.” That is not true because little boys actually get more migraines than little girls. So that tells us the genetic predisposition for sexes is about the same. As women get into the puberty, then it's the estrogen fluctuation that we think triggers migraines.

Rick:
The menstrual cycle obviously can have an enormous effect on a woman's migraines. Describe for us the physiology of estrogen and how it might affect a woman's body during menses.

Dr. Aurora:
There was a study done by Dr. Somerville published in 1972. He took six or eight women and he supplemented progesterone around the menstrual period, and there was no effect on headache. Then in the next few cycles, he supplemented estrogen, and then he stopped the migraines. What he showed was by doing that during the menstrual phase when women were getting the estrogen, the headaches didn't happen. It happened with the withdrawal of the estrogen but not with withdrawal of progesterone. So we think that it's the withdrawal of the estrogen that gives the headaches.

Rick:
The term "true menstrual migraine" is something I hadn't heard before. Can you describe for us what that is, and when would a woman know that she is having one?

Dr. Aurora:
Menstrual migraine or menstrually associated migraine is if you have migraines around the menstrual period, but you also have migraines at other times that could be, say, triggered by lack of sleep or different foods or stress or what have you. True menstrual migraine occurs two days or one day after having menstrual flow – 90 percent of that individual's headaches are just around that period – and they have less than 10 percent of headaches other times.

Rick:
Does a true menstrual migraine respond to the traditional migraine treatments? And if not, what do you do for it?

Dr. Aurora:
We have a class of drugs called the triptan class of drugs. Sumatriptan (Imitrex) was the prototype, and then we have six others. It's been shown that migraines respond well to triptans, or they respond to another class of drugs called ergotamine. The prototype of what we have is DHE, or dihydroergotamine. For some individuals, the menstrual migraine is more difficult to treat, but in general the triptans do work, and they have all been shown to work in different studies during the menstrual period as well. [Medical editor’s note: These medications are used to treat a migraine that has already begun and are called abortive treatments because they abort the headache.]

There was a study done a few years ago where they just treated with an anti-inflammatory, Naprosyn (naproxen), two days before the period and continued during the menstrual period and two days after, and that seemed to decrease the headache.

You can also have preventive treatments for migraines (which are taken daily to prevent the occurrence of migraines). The four drugs that are approved for prevention of migraine are two beta-blockers and two neuromodulators. You can also just give long acting triptans, and there is a long acting triptan called frovatriptan (Frova), which is being evaluated by the FDA (Food and Drug Administration) to see if given just around the menstrual period preemptively that it can treat the migraines.

And then the other thing that we can do is just to manipulate the hormones and put somebody on a really low dose of estrogen throughout their cycle in the form of a low dose birth control pill. That would prevent the fluctuation of the estrogen. That can be done also.

Rick:
Our topic is big life changes, and pregnancy is another big life change. What happens during pregnancy typically for a woman? Do migraines improve, or do they get worse?

Dr. Aurora:
Usually, in the first trimester when there is a lot of fluctuation going on, migraines could get worse, but in general migraines do get better during pregnancy once the hormones are more regulated. But some women have migraines for the first time when they get pregnant.

Rick:
And why would that happen?

Dr. Aurora:
Well, again, they probably have the predisposition for it. And if the hormone cycle is changing, they can have migraines triggered.

Rick:
And then when the child is born, do migraines return with their former intensity, or do they tend to get better permanently? And conversely, if they got their first migraine during pregnancy, do they go away?

Dr. Aurora:
If they occur for the first time during pregnancy, my usual experience is that about 50 percent of them remit, but 50 percent of people continue to have migraines. It's like something went off in the brain, and once that predisposition started occurring, it just kept on happening.

Rick:
Well, let's talk about birth control a little bit. I have heard that oral contraceptives can worsen migraines for some women and improve them for others. So it's a bit of a mixed message out there. Can you clarify that for us, Dr. Aurora?

Dr. Aurora:
Yes. The world of estrogen and birth control has really been revolutionized in the last 10 or so years. The high dose estrogen pill definitely made migraines worse. We did see more worsening of migraines also with a moderate dose birth control pill, which has about 30 micrograms of estrogen.

We are now seeing really low dosages of hormonal contraception that keep the hormones more even. We are talking about estrogen dosages of 20 micrograms or lower, and that seems to make the hormones kind of flatten out and not fluctuate as much, and that seems to help people with their migraines. It's the drop in the hormones that triggers migraines.

Rick:
Menopause obviously affects a woman's estrogen levels. I'm guessing then that that will exacerbate migraines because it's fluctuating again. Is that what we find?

Dr. Aurora:
Absolutely. That's one of the hardest phases of migraine to treat because the hormones are fluctuating, and there are a lot of other changes that are going on. And at that time, women also have other co morbid conditions (other illness such as heart disease and/or diabetes, etc.). There are more mood swings, hot flashes, other systemic problems. But migraines definitely get worse around that time as well.

Rick:
And in terms of that hormone replacement therapy, how seriously should a woman consider that if she is in menopause and she does find her migraines getting worse?

Dr. Aurora:
I ask people to make a choice whether to do hormone replacement independent of the migraine. So if they are not considering hormone replacement for anything else, we try other avenues to prevent migraines, especially if they are having more than one or two attacks a week and the attacks are pretty disabling. Then there are preventive medications that are approved for migraines that we can try. But if they do go on the hormone replacement route, then there are certain avenues that are a bit better for hormone manipulation or stabilization than others.

Rick:
And in general, how effective is hormone replacement at controlling migraines?

Dr. Aurora:
Well, for some people it is very, very effective. It just varies individually.

Rick:
Let's move on to talk about men for a little bit here. Are migraines just as complicated and hormone-related for men in general, or does something else commonly trigger them?

Dr. Aurora:
For men, fortunately the hormones don't fluctuate like women's hormones do. So for men we don't find that hormones play a very big role in triggering migraines. But men can have just as devastating migraines as women in terms of causing disability, missing out on social events, missing out on work, but most of the time it's not hormone-related.

Rick:
Then what is it related to? What are the common triggers for men?

Dr. Aurora:
It could be lack of sleep, food. For little boys, dehydration plays a role. If men don't drink enough water, they don't exercise as well, they don't watch what they eat, and all those can be potential triggers.

Rick:
What about stress?

Dr. Aurora:
Stress definitely is a very important trigger.

Rick:
I guess research shows that over 5 million men report that they suffer from migraines, but some experts believe the numbers are a lot higher than that and that men often do not seek medical help for their headaches. Explain to us why you think that is, Dr. Aurora. And if a man does not get help, can it have a negative effect on his overall, long term health?

Dr. Aurora:
I think men in general tend not to go to the doctor as much. In fact, there is a very interesting study where I read that men actually use the Web more to get information on health conditions. When a woman uses the Web, it's less frequently than men, but they actually act upon it. So I think it's in every condition, and I think it's just one of those gender differences.

As somebody who has really done a lot of work in migraine and made it kind of my passion in life, I feel sorry if people don't avail of our research and everything that we've done to bring the migraine treatment to what it is today. Why suffer when you actually have really good treatments?

Rick:
I would guess for the same reason men don't generally ask for directions, they probably don't go to the doctor as much.

Dr. Aurora:
That's true.

Rick:
So when men do go in for treatments, what can they expect? What medicines are typically prescribed for them these days?

Dr. Aurora:
Everybody who has an episode of migraine deserves something (medication) to take when they have a headache. And if they don't have risk factors like cardiovascular disease and are otherwise healthy, we usually give the triptan class of medications a try to see if that would work acutely. If they have a lot of frequent headaches, then we try and put them on a prevention medication, either blood pressure lowering agents (such as beta-blockers or calcium channel blockers) or one of the neuromodulators to prevent the headaches.

Rick:
Can men and women ever grow out of their migraines?

Dr. Aurora:
Yes. Actually the epidemiological research actually showed that there is a peak at 20, 30 and 40 for both men and women, and then there is a tapering off.

Rick:
We said in the introduction that we would also talk about some of the stressors brought on by big life changes that can trigger migraines. When you work with your adult patients, doctor, what are some of the most [link: http://www.healthtalk.com/migraine/programs/28_782/page04.cfm ] common stressors that they talk about?

Dr. Aurora:
They talk about work changes, marriage, divorce, death in the family, issues with children, problems with spouses, in-laws.

Sometimes I tell people if I could give them a prescription to go to a beach or go to the mountains that that would be good.

Rick:
Right. And I am wondering is it always a medicine that's prescribed, or is it a lifestyle change in conjunction with that?

Dr. Aurora:
We always work with people. Whenever somebody gets an attack, they need some treatment for it, but prevention, and a behavioral approach is so important. Keeping a log, seeing what's triggering the headaches, trying to do relaxation, trying to do biofeedback; all of these have been shown to actually work to prevent migraines.

Rick:
It's also not just the big changes, but relatively small events can stress people out. Do you see that commonly?

Dr. Aurora:
Absolutely. I saw a patient yesterday who has a headache every Friday or Saturday. He is a surgeon. His big surgery day is on Thursday. It doesn't need to happen during stress. One of the more common triggers is the letdown after the stress has passed.

I did a feature a few years ago in Bridal Magazine on honeymoon headaches. They go through all of the stress of planning the wedding, the wedding goes well, and then they go on their honeymoon, and they have a honeymoon headache.

Rick:
Okay. So summarize, if you could, your approach to treating migraines.

Dr. Aurora:
I get migraines myself, and I noticed that whenever I went to Europe or outside the U.S. to present my research, I would get migraines. So one of my big triggers is lack of sleep, and my other trigger is cigarette smoke. On my first day in Europe, if I just eat in my room and don’t go into the bar or the smoky restaurants, that I would avoid that trigger. So what I tell people is if you have a headache sometimes when you eat chocolate but a headache almost all of the time when you have your menstrual period, well, don't eat chocolate around your menstrual period.

If you can predict that have headaches on Saturday because you don't drink coffee until 10 or 11 in the morning rather than at 6 in the morning, then get up in the morning and have a little bit of coffee. So you try to modulate it. [Medical editor’s note: Some people who drink a lot of caffeine get a caffeine withdrawal headache. For some people, however, caffeine is also used to treat migraines. If you drink a lot of caffeine and you suffer from migraines, you should discuss this with your doctor.]

Rick:
We have some questions coming in via e mail, so we will get right to them. And our first one comes from Sarasota, Florida, and this listener writes, "I'm currently in the eighth month of renovating our home. It's been an extensive and complicated project. To top that, I was going through menopause. Besides the soaking night sweats every night, I have noted an increase in migraines. Do you have any specific advice for someone who also has lupus, diabetes, arthritis, adrenal insufficiency and hypothyroidism? I feel like a walking pharmacy already."

Dr. Aurora:
I think that this patient would be ideal for some of the alternative treatments that have also been shown to work for lupus and diabetes such as relaxation therapy, biofeedback and maybe acupuncture. I think that those would be really good avenues rather than another drug thrown at this person.

Rick:
Karen in Michigan wants to know if stress is a big factor in having a migraine.

Dr. Aurora:
I think stress, during stress and also the letdown after the stress, are very common in triggering migraines.

Rick:
Judy in Yuma, Arizona, writes, "My migraines are the result of a brain concussion/skull fracture for 40+ years. My age is 55. They have the same side effects as a stroke: slurred speech, blurred vision, the loss of use of the hands and legs. Usually, they last for about 30 minutes before the pain sets in and leaves me tired, sometimes for hours or days afterwards. Most prescription drugs leave me feeling in a fog. All doctors tell me is if the symptoms go away, then it wasn't a stroke, and they don't know what it was – not a great comfort. I could go to the hospital each time I have a migraine and get the runaround and some expensive tests. I feel I am in a dilemma."

So what might be next for this person, an MRI perhaps?

Dr. Aurora:
If they haven't had an MRI, yes. And what they seem to be having is a migraine aura with the migraine. I don't think that this sounds like the symptoms of stroke. Of course, the physician who is evaluating them would probably know best. But this type of person I would actually put on migraine preventive drugs because once they get the migraines the options of treatment are not great because the triptans or the ergotamines can't be given if people have weakness or slurred speech or incoordination with their migraines. So something to prevent the headaches every day, like a neuromodulator, is probably the way I would go. [Also see: [link: http://www.healthtalk.com/migraine/diseasebasics05.cfm] How is migraine treated?]

Rick:
We have an e mail from Mount Dora, "What about weather related migraines? I seem to get migraines when the weather goes from sunny to stormy."

Dr. Aurora:
Yes, definitely. Living in Washington, I can tell you that there are some people here who can tell me when a storm is coming depending on the migraine. Barometric pressure and weather changes affect the area of the brain called the hypothalamus, which has been known metabolically to change when somebody has a migraine. So we think that weather is one of the factors that could affect somebody having migraines. There is very little you can do about the weather. During the really bad weather fluctuation season, they might consider going on a preventive medication.

Rick:
And another weather related question from Michael in Missouri asks, "Is there a correlation between hot, humid summer weather and migraines? I have many more migraines in the summer than at any other time of the year."

Dr. Aurora:
For some people, it's summer. For some people, it's the clouds. It just varies. One of the studies that we have done showed that people, even in between the attacks, are very light sensitive. So I recommend wearing sunglasses, even maybe wraparound sunglasses so that light should not trigger the headaches. And watch out for dehydration by drinking plenty of water. Avoid a lot of exposure to humidity.

Rick:
This next e mail says, "I get migraines at least once a month ever since I had a hysterectomy. The only thing that helps is Imitrex (sumatriptan) and sleep. They last from two to three days. Why do I get them, and what can I do to stop them? I had them in my 20s, but not in my 30s and 40s. I am now 51 years old."

Dr. Aurora:
Well, it sounds as though they are still going through the hormonal changes of perimenopause, and that's probably what's triggering the migraines. And if somebody is having them just once a month, I don't think that that's person who is a very good candidate for migraine prevention, but definitely their treatment can be optimized. So it would depend on what dose of Imitrex they are taking. Maybe they need to combine Imitrex with a nonsteroidal antiinflammatory or maybe switch to another triptan to see if that might help their migraines more.

Rick:
Check with your own doctor and find out the options there.

Dr. Aurora:
Yes.

Rick:
An e mail from Leslie in Sarasota Springs, New York says, "I am 53 years old and have had daily tension type migraines for over 30 years. Nothing has helped. I had a complete hysterectomy 20 years ago. It didn't change a thing. I have been to Diamond Headache Clinic and will consult with Dr. Silverstein at Thomas Jefferson in Philadelphia in October. Nothing helps, not facet injections, Botox, acupuncture, pills, Imitrex. All of them do nothing. I believe I'm running out of options. What do you think I should do next?"

Dr. Aurora:
I think that going to a headache specialist and a program like the Jefferson Institute can offer cutting-edge research. It sounds as if this person has chronic migraines, and we have over the last three or four years concentrated on chronic migraines, so there are more ongoing research trials besides what they have maybe tried that didn't help.

Rick:
Deb in Milpitas, California, has a question, something we touched on briefly in the program, "Do migraines tend to increase or decrease with age? And do you see where they stop altogether once you hit a certain age?"

Dr. Aurora:
Well, that age varies, but for most people migraines do decrease with age, but I can't tell you one particular magic number. I have an 86 year old in my practice. I have a 92 year old in my practice. And they still have migraines.

Rick:
We have an e mail from Diana in Royal Oak, Michigan, and she writes, "I have had migraine headaches since I reached puberty. Is there any medicine I can take? My doctors don't want to give me Imitrex (sumatriptan). I used to take MigraHealth, and that worked very well, and then it was no longer available. A new one came out that's called MigreLief [Medical editors Note: These two products are classified as supplements and have not been evaluated by the Food and Drug Administration for effectiveness], but it doesn't work as well as the others, and it's more expensive. It seems to me something should be available. If anyone has suffered from migraines, they know how they hurt."

So what can you tell Diana?

Dr. Aurora:
MigraHealth used to be made by a company that put a combination of magnesium, riboflavin and feverfew together. The company that used to make MigraHealth was sold to the company who then changed its name to MigreLief, and to my knowledge they were interchangeable. But if they find that it's not interchangeable, there is another compound over the counter called Migravent. And what that has is magnesium, riboflavin, feverfew, but it also has butterbur. Those are supplements that if they worked in the past that this person might try.

Rick:
An e mail from Center, Alabama says, "My doctor lowered the dosage of my hormone medicine. Would that cause migraines to occur more often?"

Dr. Aurora:
Well, it's probably during that fluctuation, so yes. If the hormone levels change during the changing phase, migraines could have occurred.

Rick:
A question about acupuncture comes to us from Tucson. This person says, "I had a radical hysterectomy two years ago at the age of 44. I am taking one milligram of estradiol (Estrace, Climara, Estraderm). If I am late with a pill or miss it, I immediately get thrown into a three day migraine. My gynecologist says this will get worse when I stop this medication. I only take over the counters at this time. Sometimes ice to my neck helps, as well as a chiropractor. What do you think about [link: http://www2.healthtalk.com/go/migraine/encyclopedia/?p=1/002064.htm ] acupuncture?"

Dr. Aurora:
I think acupuncture when it works, it works great. It's a great form of alternative treatment. It does not have any side effects in terms of systemic side effects like kidney disease or anything like that. It has never been shown to work in a scientific study, but I have anecdotal experience from my patients that it works really well.

Rick:
What's your sense of how often it will work for someone?

Dr. Aurora:
Well, I think it's like a 30 percent rule. So 30 percent of the time it does work.

Rick:
An e mail from Charlie in Topeka, Kansas says, "I just moved to a new city, and my migraines are becoming more frequent. I am also interviewing for jobs. Is there anything I can do like schedule a massage or take a yoga class that might help?"

Dr. Aurora:
Absolutely. I think anything to relieve some of the stress would help.

Rick:
E mail from Sausalito, California asks, "My migraines have gone from nine a month to almost daily since I entered perimenopause. Preventives have never worked for me. Any other ideas? My neurologist says no estrogen for me as I have had auras with the migraines."

Dr. Aurora:
When people come to me, and they say, “I’ve tried all the preventions,” sometimes they are talking about trying a medicine for two days or trying a medicine for a month and giving up on it. We like to put them on an adequate dose for at least three months. And I would say consult a headache specialist in your area.

Rick:
And the comment "my neurologist says no estrogen because of the auras," what's the connection there?

Dr. Aurora:
Well, there is an increased risk of stroke with hormone replacement, and there is also a slightly increased risk of stroke if you have migraine with aura. So if you add all these, maybe the risk of stroke is a little bit higher. Now, you have to just weigh the pros and cons because I think someone who is having daily headaches, sometimes quality of life is not where they want it to be, so they might want to consider hormone replacement and have a small risk of stroke.

Rick:
E mail comes to us from Gail in Pennsylvania. She says, "My husband had a terrible accident. He fell 36 feet off a building. I also have four teenagers living at home. I feel like all these heavy burdens and stress have a definite influence on my migraines. What should I do?"

Dr. Aurora:
Stress relaxation, yoga, meditation definitely help. But then you have four kids at home, a husband probably disabled; now where do you find the time to do it? And I always tell people you have to consider how much time you're taking off because of a migraine. You have to factor that in and see if you can devote that to migraine prevention.

Rick:
Here's a question about chiropractic, "Do you think chiropractic will help? Does it improve migraines?"

Dr. Aurora:
In general, we don't recommend chiropractic maneuvers especially to the neck area because high velocity manipulations have also caused the dissection of arteries (a dissection is when a tear in the lining of the artery causes blood to travel inside the wall of the artery, which can rupture). In the low back if there is manipulation, that's not a problem really because there is no big artery there. I don't really recommend that people manipulate their neck to try and fix the headache.

Rick:
An e mail from Loma Linda, California asks, "I have suffered from migraines since I was a little girl. I couldn't go anywhere in a car, boat or bus because I always got dizzy, nauseous, headachy." Something we mentioned earlier, "My parents were scared to take me out. I am now 50. Migraines still attack me every month before or after my period. I'm on a medication, propranolol (Inderal) twice a day, and sometimes I have to take Imitrex 100 milligrams too. I just want to know when am I going to be free from migraines?"

Rick:
An e mail from Margo in Orlando, Florida, asks "I am 33. I've had debilitating migraines during my period ever since I hit puberty. My mother also had the same condition. I am currently pregnant, with a girl. Is there anything I can do to help prevent migraines for my daughter?"

Dr. Aurora:
Just watch for headaches, and then get her into a specialist because we have demonstrated that the sooner people seek help for their migraines, the more it does help in the long run.

Rick:
We are just about out of time, but before we go, I would like to get your final thoughts. What would you like to leave our listeners with today, Dr. Aurora?

Dr. Aurora:
I would definitely like to say that we've come a long way in migraine treatment. We do a lot of research. We know the mechanism of migraine. We know what happens during a migraine in the person's brain and we've come up with targeted treatment. We'd like everybody to at least know that there is treatment available specifically for migraine. And for those people who have a lot of migraines, now there are four drugs that are approved for migraines, and we continue to find more. Thank you.

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